Provider Demographics
NPI:1861965550
Name:GULLEY, PRINCE-TYSON AHMAD
Entity type:Individual
Prefix:MR
First Name:PRINCE-TYSON
Middle Name:AHMAD
Last Name:GULLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:937 PENN AVE
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44311-1919
Mailing Address - Country:US
Mailing Address - Phone:330-535-7278
Mailing Address - Fax:
Practice Address - Street 1:937 PENN AVE
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44311-1919
Practice Address - Country:US
Practice Address - Phone:330-535-7278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-07
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator